Alternatives to mental health admissions for children and adolescents experiencing mental health crises: A systematic review of the literature

Abstract

Background: Many children and young people (CYP) presenting with mental health crises are admitted to hospital due to concerns around illness severity and risk. Whilst inpatient admissions have an important role for such children, there are a number of burdens associated with them, and safe avoidance of admissions is favourable. We systematically reviewed the literature for studies of interventions reported as alternatives to a hospital admission in CYP presenting with mental health crises, in any inpatient setting. Methods: Three databases (PsychInfo, PubMed and Web of Science) were searched for peer-reviewed papers in October 2020, with an updated search in May 2021. Results: We identified 19 papers of interventions delivered in the emergency department, the home, outside of home but outside of clinics and in hospital clinics. The quality of most included studies was low, with less than half being randomised controlled trials and only half of these at low risk of bias. The best quality studies and greatest evidence for efficacy came from in-home interventions, in particular multisystemic therapy, which improved psychological outcomes, and though a large number of CYP still ended up being admitted, there appeared to be decreased length of stay. Conclusions: Overall, we could not recommend a particular intervention as an alternative to inpatient admission; however, our review describes benefits across a range of types of interventions that might be considered in multi-modal treatments. We also provide recommendations for future research, in particular the evaluation of new interventions as they emerge.

Models of integrated care for young people experiencing medical emergencies related to mental illness: a realist systematic review

“…Innovations for integrated care show promising evidence for reducing the rate of emergency admissions to an acute ward, the LOS in both the emergency department and inpatient setting, and the rehospitalisation rate after discharge. Thus, integrated care not only improves health outcomes [ 17 , 18 ] and effectively reduces psychiatric hospitalisation [ 19 ]—this review adds that signposting to psychological interventions also reduces emergency readmissions in paediatric emergency settings too. Whilst there is sometimes no alternative to hospitalisation for medical emergencies [ 16 , 17 ], integrating psychiatric care into emergency services helps to triage effectively, intervene earlier, and signpost to therapeutic support, reducing lengthy and repeat hospitalisation.…”

“…The effectiveness of therapeutic modalities on improving health outcomes is well documented. [ 17 ] For example, integrating family-based therapy within acute hospitalisation has been provided in medical emergencies that are accompanied by a comorbid mental illness—particularly eating disorders and suicide attempts. This is known as partial hospitalisation, which involves transferring the patient from an inpatient ward to outpatient family-based therapy once medical stabilisation is complete; aimed at reducing the degree of institutionalisation [ 18 ].…”

“…One example of integrated care is providing psychological assessment and treatment, subject to the patient being well enough to participate, alongside acute medical care [ 20 ]—instead of prolonged hours of unstructured time and social isolation on an acute ward. These innovations have implications not only for improving health outcomes [ 11 , 17 ], but most importantly to avoid institutionalisation by minimising time spent in hospital and supporting return to a home environment [ 17 ].…”

Adolescent Inpatient Mental Health Admissions: An Exploration of Interpersonal Polyvictimization, Family Dysfunction, Self-Harm and Suicidal Behaviours

“…Mental health disorders, especially those of greater severity, negatively influence the adolescent's overall quality of life. If left untreated, mental health disorders can result in several While inpatient settings are instrumental in stabilizing severe mental health disturbances, they may also carry burden [22], such as being costly for the healthcare system [23], having limited capacity [24] and requiring disconnection from family, friends, education and employment. Thus, safe and effective alternatives to inpatient admissions in community settings are favoured [22].…”

“…Traditionally, inpatient admissions were reserved for comprehensive evaluations [9], the stabilization of symptoms and the reduction of imminent risk [10] among individuals with severe behavioural or emotional disturbances [11][12][13]. However, recent studies have suggested an increase in both emergency room visits and hospitalizations that are not thought to have occurred solely due to medically serious suicide attempts [14] or heightened mental health conditions [15,16]. The etiology of mental health conditions is complex and is associated with a number of factors, including but not limited to, individual characteristics (e.g., sex) [17,18], interpersonal relationships [19] and traumatic life events (e.g., physical assault, sexual abuse) [20].…”